Jonathan P. Eskander

Use of the trauma pelvic orthotic device (T-POD) for provisional stabilisation of anterior-posterior compression type pelvic fractures: a cadaveric study.

OBJECTIVE To demonstrate that a commercially available pelvic binder the trauma pelvic orthotic device (T-POD) is an effective way to provisionally stabilise anterior-posterior compression type pelvic injuries. METHODS Rotationally unstable pelvic injuries were created in 12 non-embalmed human cadaveric specimens. Each pelvis was then stabilised first with a standard bed sheet wrapped circumferentially around the pelvis and held in place with a clamp. After recreating the symphyseal diastasis, the pelvis was stabilised with the T-POD. Reduction of the symphyseal diastasis was assessed by comparing measurements obtained via pre- and post-stabilisation AP radiographs. RESULTS The mean symphyseal diastasis was reduced from 39.3mm (95% CI 30.95-47.55) to 17.4mm (95% CI -0.14 to 34.98) with the bed sheet, and to 7.1mm (95% CI -2.19 to 16.35) with the T-POD. CONCLUSIONS Although both a circumferential sheet and the T-POD were able to decrease symphyseal diastasis consistently, only the T-POD showed a statistically significant improvement in diastasis when compared to injury measurements. In 75% of the cadaveric specimens (9 of 12), the T-POD was able to reduce the symphysis to normal (<10mm diastasis). Both a circumferential sheet and the T-POD are effective in provisionally stabilising Burgess and Young anterior-posterior compression II type pelvic injuries, but the T-POD is more effective in reducing symphyseal diastasis.

Imaging in pelvic osteomyelitis: support for early magnetic resonance imaging

Background: Children with pelvic osteomyelitis may present with symptoms that are nonspecific. Conventional imaging modalities including plain radiographs, ultrasound, technetium bone scan, and computed tomography rarely demonstrate pathology that is diagnostic of this condition. As a result, accurate diagnosis is often delayed, and children may undergo surgical diagnostic or therapeutic procedures that may be avoided. We report the radiographic and magnetic resonance imaging (MRI) findings in 23 children admitted with a suspected diagnosis of pelvic osteomyelitis. We are presenting imaging findings in children with suspected pelvic osteomyelitis with emphasis on MRI abnormalities and to propose an anatomical classification based on the patterns of pelvic involvement. Methods: The medical records and imaging reports of all patients admitted to our institution with a history and physical examination suggestive of pelvic osteomyelitis between July 31, 1992, and March 10, 2003 were reviewed. Criteria were defined for the diagnosis of pelvic osteomyelitis based on criteria used by Farley et al in 1985. Specific attention was paid to the imaging strategies used and the influence of each radiographic method on the ultimate diagnosis. Results: Abnormalities on the MRI included soft tissue inflammation and bone edema. These findings were bright on T2 and short inversion time Short T1 inversion recovery (STIR) images and enhanced after gadolinium administration. Five distinct patterns of pelvic involvement were observed, each corresponding to a cartilaginous epiphysis or apophysis. These were the sacroiliac joint, triradiate cartilage, pubic symphysis, ischium, and iliac apophysis. One patient had a noninfectious cause of presentation with a deep vein thrombosis, whereas another was diagnosed with Hodgkin lymphoma in addition to osteomyelitis of the ischium. Conclusions: Magnetic resonance imaging is a sensitive technique for evaluation of pyogenic infections involving the pelvis. In patients presenting with clinical findings and laboratory studies suggesting an infectious process, MRI with gadolinium enhancement should be performed as an early study. Magnetic resonance imaging is also effective in identifying other conditions that may resemble pelvic osteomyelitis. Level of Evidence: This is a level II diagnostic study.

The association between preoperative spinal cord rotation and postoperative C5 nerve palsy

BACKGROUND C5 nerve palsy is a known complication of cervical spine surgery. The development and etiology of this complication are not completely understood. The purpose of the present study was to determine whether rotation of the cervical spinal cord predicts the development of a C5 palsy. METHODS We performed a retrospective review of prospectively collected spine registry data as well as magnetic resonance images. We reviewed the records for 176 patients with degenerative disorders of the cervical spine who underwent anterior cervical decompression or corpectomy within the C4 to C6 levels. Our measurements included area for the spinal cord, space available for the cord, and rotation of the cord with respect to the vertebral body. RESULTS There was a 6.8% prevalence of postoperative C5 nerve palsy as defined by deltoid motor strength of ≤ 3 of 5. The average rotation of the spinal cord (and standard deviation) was 2.8° ± 3.0°. A significant association was detected between the degree of rotation (0° to 5° versus 6° to 10° versus ≥ 11°) and palsy (point-biserial correlation = 0.94; p < 0.001). A diagnostic criterion of 6° of rotation could identify patients who had a C5 palsy (sensitivity = 1.00 [95% confidence interval, 0.70 to 1.00], specificity = 0.97 [95% confidence interval, 0.93 to 0.99], positive predictive value = 0.71 [95% confidence interval, 0.44 to 0.89], negative predictive value = 1.00 [95% confidence interval, 0.97 to 1.00]). CONCLUSIONS Our evidence suggests that spinal cord rotation is a strong and significant predictor of C5 palsy postoperatively. Patients can be classified into three types, with Type 1 representing mild rotation (0° to 5°), Type 2 representing moderate rotation (6° to 10°), and Type 3 representing severe rotation (≥ 11°). The rate of C5 palsy was zero of 159 in the Type-1 group, eight of thirteen in the Type-2 group, and four of four in the Type-3 group. This information may be valuable for surgeons and patients considering anterior surgery in the C4 to C6 levels.

Is there a difference between simultaneous or staged decompressions for combined cervical and lumbar stenosis

Study Design We evaluated 43 patients diagnosed with tandem spinal stenosis (TSS) from 1999 to 2005 in an academic hospital. Objective The purpose of this study is to compare outcomes after simultaneous decompression of the cervical and lumbar spine versus staged operations. Summary of Background Data TSS is a rare degenerative disease affecting multiple spinal levels with limited research describing operative management. Methods Of our patients, 21 underwent simultaneous decompression of both the cervical and lumbar spine and 22 underwent staged decompression of the cervical spine followed by the lumbar spine at a later date. Medical records were reviewed for patient demographics, type and duration of symptoms, operative time, combined blood loss, cervical myelopathy modified Japan Orthopaedic Association Score, Oswestry Disability Index (ODI), major and minor complications, and average length of follow up. Each category was evaluated by Pearson correlations and unpaired Student t tests. Results With a mean follow-up of 7 years, both groups improved in JOA and ODI without a significant difference between the 2 operative groups in terms of major or minor complications, JOA, or ODI. Independent of the surgical algorithm, age above 68 years, estimated blood loss ≥400 mL, and operative time ≥150 minutes significantly increased the number of complications. Conclusions These results indicate that TSS can be effectively managed by either surgical intervention, simultaneous, or staged decompressions. However, patient age, blood loss, and operative time do significantly impact outcomes. Therefore, operative management should be tailored to the patients age and the option which will limit blood loss and operative time, whether that is by simultaneous or staged procedures.

Revision strategy for posterior extrusion of the CHARITE polyethylene core

Study Design. This is a case report of a posterior extrusion of the polyethylene core from a CHARITÉ arthroplasty. This is the first reported case of posterior dislocation of the polyethylene and the revision strategies used to correct this problem. Objective. To report a novel failure mechanism and revision strategy for CHARITÉ total disc arthroplasty (TDA). Summary of Background Data. Case report at a Level 1 tertiary care referral center in the northeastern United States. Methods. This is a case report and review of the literature of a patient who sustained posterior dislocation of the polyethylene core from a CHARITÉ TDA several months after the index procedure. Results. Core dislocation is a known complication of TDA. However, of the known reported dislocations all have been anterior. This case describes the first known occurrence of posterior core dislocation and the revision strategy for this problem. Conclusion. This case report highlights the first known case of a posterior dislocation of a CHARITÉ core. It is likely that altered biomechanical forces generated over time attributed to device failure. An instrumented posterior fusion with removal of the core is what ultimately led to a stable revision construct.

Injury of an aberrant vertebral artery during a routine corpectomy: a case report and literature review

Case report:A case report of a 58-year-old man who sustained a laceration of his left vertebral artery during a routine corpectomy for cervical myelopathy is reported.Objective:To report iatrogenic injury of a tortuous vertebral artery during anterior cervical spine surgery and discuss appropriate diagnosis and treatment options for this complication.Setting:UMass Memorial Medical Center, Worcester, MA, USA.Background data:Vertebral artery anomalies, although rare, are typically present with degenerative processes and great care must be taken to avoid damage during a corpectomy. Cross-sectional imaging coupled with intraoperative angiography is helpful for the urgent evaluation of the injury site and identification of the contralateral vertebral arterys status.Methods:This is a single case of a patient sustaining a laceration of the left vertebral artery during surgery, which resulted in a lateral medullary stroke.Results:After the left vertebral artery laceration, hemostasis was achieved. With the intent to better visualize and possibly embolize or stent the injury, an angiographic study was carried out. The angiogram revealed a laceration of the left vertebral artery within the vertebral foramina at vertebral body level C6, but intact distal flow. The patient underwent angiographic embolization and a subsequent magnetic resonance imaging (MRI) revealed a left lateral medullary stroke consistent with the lack of flow through the left vertebral artery from C6 to the basilar artery.Conclusion:If a tortuous vertebral artery is suspected, then meticulous review of preoperative cross-sectional imaging should be implemented along with angiographic examination. If anomalies are detected and the standard procedure cannot be safely carried out, then alterations, such as preoperative stent placement, need to be considered.

Identification of type 1: interforaminal vertebral artery anomalies in cervical spine MRIs.

Study Design. This is a prospective study. Objective. The aim of our study is to identify whether vertebral arteries (VA), normal or aberrant, are routinely described in cervical spine magnetic resonance imaging (MRI) interpretations. Summary of Background Data. VA injury is a serious complication of anterior cervical spine surgery. Aberrant VA anatomy is a potential cause of such complications. Therefore, VA anatomy should be evaluated in cervical MRIs. Methods. Six neuroradiologists were blinded to the study design and were asked to interpret 79 cervical MRIs. Of these, 39 had aberrant VAs, whereas 40 had normal VAs. Initially, the indications for the study included only a description of patients symptoms. The radiologists were then given the same MRIs with different indications. This time, the indications included the patients symptoms, a request for annotations on the VA, and a definition of VA anomaly. All of the MRI interpretations were then evaluated for the frequency and accuracy of VA description. Results. When the indications for the study did not specifically request a comment on VAs, the VA was never described (0%). When the indications included the specific request and definition, all 6 commented on the VA (100%). Three of the 6 radiologists were 100% accurate in identifying all 40 normal and 39 aberrant VAs, whereas the other 3 identified all 40 normal and 38 of 39 aberrant VAs. Conclusion. This study demonstrates that the VA is not a standard component of cervical spine MRI interpretations. Because of the significant complications related to its injury, VA anatomy, whether normal or variant, needs to be evaluated in cervical MRIs. When ordering a cervical MRI, surgeons should request a description of the VA and any anomalies.

A left knee wound complication by non-Hodgkins lymphoma in bilateral total knee arthroplasties

A 70-year-old woman with a history of bilateral primary knee osteoarthritis presented with a left knee wound complication, a non-Hodgkins lymphoma, after bilateral total knee arthroplasties. After exploring several etiologies, the evidence in this unusual case suggests a coincidental preexisting lymphoma.

Spinal Metastases from a Primary Fallopian Tube Serous Adenocarcinoma: A Case Report

Study Design Case report. Objective This case exemplifies the importance of a high index of suspicion when dealing with intractable pain and neurologic symptoms in patients with a history of cancer. Fallopian tube cancer is relatively uncommon, accounting for less than 0.2% of all female malignancies. Because of a low index of suspicion, it is often detected at an advanced stage. From an orthopedic perspective, osseous metastasis from primary fallopian tube malignancies is rare with only a few documented cases in the medical literature. Methods This case report documents a 68-year-old woman who developed back pain and leg weakness after undergoing surgical resection with adjuvant therapy of a primary fallopian tube adenocarcinoma. Her hospital course and follow-up are documented. Results Imaging revealed a compression fracture in the L1 vertebral body that when a biopsy confirmed a soft tissue diagnosis of a high-grade serous papillary adenocarcinoma of fallopian tube origin. The patient underwent a surgical decompression, posterior stabilization, and tumor debulking with postoperative resolution of her symptoms. Conclusions This is the first reported case of a spine metastasis from a fallopian tube serous carcinoma in a living patient. This case documents the diagnosis of a pathologic vertebral fracture due to metastasis of an atypical cancer.

A modified technique for dowel fibular strut graft placement and circumferential fusion in the setting of L5-S1 spondylolisthesis and multilevel degenerative disc disease

BACKGROUND Traditional techniques for the treatment of isthmic spondylolisthesis pass a fibular dowel graft across the L5-S1 disc by using the anterior portion of the L5 body. OBJECTIVE To introduce a technique for the treatment of isthmic spondylolisthesis in the setting of multilevel degenerative disc disease in adults. Our modified technique allows us to traverse the L5-S1 disc via the L4-5 disc space thereby treating the degenerated disc at L4-5 simultaneously. METHODS A standard anterior discectomy was performed on L4-5. Using biplanar fluoroscopy, a Kirschner wire was placed beginning at the anterior third of the L5 superior endplate and ending at S1. An anterior cruciate ligament reamer was used to make a channel for the fibular allograft. Then, a femoral ring allograft was placed in the disc space at L4-5, and standard anterior lumbar interbody fusions were performed at any additional cephalad level(s). Afterward, posterior instrumented fusion was performed to complement the anterior fusion procedure (except at L5), and wide decompression followed. RESULTS All patients presented with isthmic spondylolisthesis and all had multilevel fusions. The mean slip angle was 32.6 degrees (37.8 degrees preoperatively), and mean lumbar index was 67%. After the procedure, the average endplate-to-dowel angle was 107.1 degrees compared with 134 degrees. All patients had clinical and radiographic evidence of solid fusion without the need for revisions. CONCLUSION The proposed advantage of our modified technique is twofold. The graft is placed nearly perpendicular to the L5-S1 interface, as it will behave more efficiently with respect to interfragmental compression. Also, surgeons gain access to fuse L4-5 anteriorly and posteriorly.